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General NPI Number Information
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NPI Number | 1598922122
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Entity Type | Organization
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Legal Business Name | SOUTH SIDE GUADALUPE DENTAL CLINIC INC
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Dates
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Enumeration Date | 05/21/2008
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Last Update Date | 05/21/2008
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Provider Practice Location Address
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Address Line | 1112 S 3RD ST
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City | MILWAUKEE
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State | WI
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Zip | 53204-2413
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Country | US
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Telephone | 414-643-8787
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Fax | 414-643-9725
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Provider Business Mailing Address
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Address Line | 1112 S 3RD ST
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City | MILWAUKEE
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State | WI
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Zip | 53204-2413
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Country | US
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Telephone | 414-643-8787
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Fax | 414-643-9725
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Authorized Official
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Title or Position | CLINIC MANAGER
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Name | MRS. MARIA LETICIA MONJE
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Credential |
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Telephone | 414-643-8787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State | WI
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